Best practices for scanning patient records into an EHR

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The success of an electronic health records (EHR) system implementation is massively dependent on how you handle your existing paper records.

Unless these records are scanned and properly abstracted, you’re at risk of running two systems instead of one, and not realizing the ROI from your transition to electronic medical records and your investment in EHR technology.

Scanning and abstracting done right

To avoid these outcomes, here are several best practices to follow when scanning and abstracting paper patient records.

1. Plan your staffing needs

Typically you need one scanner/abstractor for every two physicians in practice. Do you need to hire outside help, or can your existing staff handle the extra work and time away from their core duties?

Knowledge and experience are two other key factors to consider when it comes to staffing. To avoid problems later, the scanning and abstracting both need to be performed by experience knowledge workers – people who know what patient records look like and who are familiar with scanning techniques and equipment. Whether you make use of in-house staff or outsourced workers, you’ll want to build in some time for training.

2. Assign a dedicated project space

Your imaging project will need sufficient dedicated space that can be used for as long as the process takes. The average requirement is around 200 sq./ ft. per person, which includes room for a workstation, a chart and file “staging” area, carts and all the necessary equipment.

3. Get the right equipment

The right equipment and software can help speed up the process and reduce human error. This will help ensure that image quality will be high, which is a key factor in the success of the EHR system. When considering equipment, look for:

• Industry standard software and maintenance
• Production level document scanners and maintenance
• Professional services and upgrades

4. Use standardized abstraction codes

To ensure uniformity and consistency of charts and reporting, it is critical to use a standard of rules for data entry.  For instance, take two doctors entering information about a patient’s heart path. One doctor might follow a rule that dictates entering vessels in order, followed by the graph and percent occlusion. But a pacemaker doctor might just enter a three-vessel CABG. Seemingly small differences like these can have significant negative impacts including worker confusion, service delays and poor system adoption.

Following standards promotes quick access to information, ease of use and long-term success for the EHR.

5. Build quality control into the process

Obviously, when it comes to imaging patient records, accuracy is paramount. A doctor relying on wrong information is a huge liability and opens up your organization to significant risk. You must have a reliable, multi-step quality control process in place to guarantee the accuracy of scanned and abstracted patient charts.

Many medical professionals we have worked with expressed surprise at how much there is to know about the scanning and abstraction process. However, don’t let this discourage you when embarking on the EHR process.  By looking at these issues early in the process, every healthcare practice can make a successful transition to EHR, avoiding the risks and realizing the full benefit of these powerful systems.

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